Background: Laparoscopic sacropexy with mesh implantation is one of the most widely adopted minimally invasive techniques for the treatment of genital prolapse. Despite its long term use, published data on its efficacy remain heterogeneous.

Objective: To evaluate the anatomical and functional outcomes of laparoscopic sacropexy using different mesh shapes and to determine their influence on relapse risk.

Methods: The study included 145 women who underwent laparoscopic sacropexy at the Surgical Clinic of Azerbaijan Medical University. Patients were examined preoperatively and at 1, 6, and 12 months postoperatively. POP Q measurements, urodynamic parameters, and surgical outcomes were analysed in relation to mesh configuration (flat mesh for posterior wall, flat mesh for anterior + posterior walls, Y-shaped mesh).

Results: Use of different mesh shapes was associated with significant variation in surgical technique and patient age (p < 0.05). Anatomical recovery after 12 months reached comparable levels across all three groups (p > 0.05). Functional disorders and recurrence rates varied: overall recurrence of cystocele or apical prolapse was 18.2 ± 5.4 %, 23.2 ± 6.4 %, and 6.8 ± 3.3 % for posterior, anterior + posterior, and Y-shaped meshes, respectively.

Conclusions: Although anatomical and functional outcomes were broadly similar, the Y-shaped mesh yielded a significantly lower recurrence rate, suggesting it as the most effective configuration for laparoscopic sacropexy in genital prolapse management.

Laparoscopic sacropexy with mesh is among the most widely used methods in the treatment of genital prolapse. Despite its long term application, publications continuously present differing data concerning its effectiveness. German researchers have performed laparoscopic sacropexy with mesh in various forms — to the cervical stump, the vaginal vault, and with preservation of the uterus — obtaining residual rates of cystocele in 7.1–15.2 % of cases and rectocele in 0–5.7 %. [1]

The risk of intra operative and post operative complications, as well as the necessity for re operation after 24 months (12.8 % and 11.8 %), has been found to be similar between patients under 70 years and those over 70 years of age. [2] Outcomes of laparoscopic lateral suspension and laparoscopic sacropexy have been shown not to differ significantly. [3] Favourable results have also been reported when laparoscopic sacropexy and pectopexy techniques are applied. [4, 5]

Laparoscopic sacropexy with mesh and transvaginal mesh reconstruction surgeries for cystocele management differ in therapeutic complication rates (17 % and 26 %). Sexual activity is believed to make laparoscopic sacropexy preferable in women of reproductive or sexually active age. [6] Successful cases of laparoscopic sacrohysteropexy preserving the uterus have also been described. [7]

A comparison between laparoscopic pectopexy and sacropexy has demonstrated that, since pectopexy does not reduce the pelvic cavity volume, disorders of defaecation do not develop. [8] Observations conducted for 24.2  ±  17.6 months after laparoscopic sacropexy show that anatomical healing occurs in 90.4 % of cases. [9] Robotic performance of laparoscopic sacropexy has not been associated with additional adverse effects. [10–12]

A systematic review devoted to the management of severe uterine prolapse confirmed that laparoscopic surgery results in less blood loss and shorter hospitalisation duration. [13] French data from 2019 show that the outcomes of laparoscopic sacropexy depend on the surgeon’s experience. [14]

Laparoscopic sacropexy has been found to have distinct advantages over laparoscopic hysterectomy. [15] Therefore, many factors can influence the results of laparoscopic sacropexy. However, the direct effect of mesh shape on the outcomes of laparoscopic sacropexy using mesh has not yet been adequately investigated.

To evaluate the anatomical and functional outcomes of laparoscopic sacropexy using mesh in the treatment of genital prolapse, the recurrence risk of apical and anterior vaginal wall descent, and to assess how these outcomes depend on the shape of the mesh applied.

The clinical observation was conducted at the Surgical Clinic of the Azerbaijan Medical University. The study included the results of 145 laparoscopic sacropexy operations.

All patients were examined pre operatively and then at 1, 6, and 12 months post operatively according to a standard protocol.

The examination process included the following indicators: age, body mass index, menopausal status, anatomical measurements according to the POP Q system, cystometry data, stress and latent urinary incontinence, post void residual volume, detrusor activity, type of operation, fixation to the sacral promontory, number of fixation sutures on vaginal walls, the shape of mesh used (posterior wall flat, anterior + posterior walls flat, or Y shaped), and mesh length.

Clinical outcomes assessed: lumbar pain, blood loss, length of hospital stay, operation time, concurrent procedures, additional surgical interventions, and relevant anamnesis.

POP Q (Pelvic Organ Prolapse Quantification) System Definitions [16]

•  Aa: a point on the anterior vaginal wall 3 cm proximal to the hymen ring.

•  Ba: the most distal point located between Aa and C.

•  Ap: a point on the posterior vaginal wall 3 cm proximal to the hymen.

•  Bp: the most distal point on the posterior vaginal wall located between Ap and D.

•  C: the anterior lip of the cervix.

•  D: the posterior fornix.

•  TVL: total vaginal length.

•  Gh: distance from the external urethral meatus to the posterior edge of the hymen.

•  Pb: distance from the posterior hymenal edge to the anal opening.

Quantitative variables (POP Q indicators, age, BMI) were processed using the Data Analysis package in Microsoft Excel to calculate the mean, standard error, mode, median, variance, and skewness.

Qualitative features (cystometric data, surgery characteristics and outcomes) were analysed for their frequency per 100 patients, standard error, and 95 % confidence interval.

The statistical significance of changes over the observation period, depending on the mesh shape, was evaluated for quantitative indicators by analysis of variance (ANOVA) and for qualitative traits by Pearson’s chi square test. [17]

A p value <0.05 was considered statistically significant.

Women who underwent laparoscopic sacropexy using meshes of various shapes differed according to age (p < 0.05). The Y shaped mesh was mainly used in the treatment of relatively older women (Table 1).

Sacropexy, performed by placing a flat mesh only on the posterior vaginal wall, was carried out mainly among younger women. The comparison groups did not differ significantly in body mass index (p > 0.05). The main characteristics of the surgical interventions in these groups are presented in Table 2.

During sacropexy using the Y shaped mesh, fixation of the uterus to the sacral promontory was performed exclusively by sutures. When using a flat mesh placed on the anterior and posterior vaginal walls, the fixation was achieved by sutures in 97.7 ± 2.3 % of cases; when the mesh was placed only on the posterior wall, fixation by sutures was employed in 75.8 ± 7.5 % of cases. The number of sutures placed on the uterus differed markedly among the three groups. A similar pattern was observed for the number of sutures placed on the cervix and the vaginal apex.

The dimensions of vaginal dissection also differed significantly between groups. Thus, the main parameters of laparoscopic sacropexy using mesh varied depending on the shape of the mesh and were not identical among the groups.

Pre  and post operative POP Q values are presented in Table 3. As shown, before surgery, the Aa parameter differed significantly among the groups. The group where only the posterior vaginal wall was reinforced with a flat mesh mainly included younger women (mean age 41.4 ± 1.8 years, median 38 years). In this group, the Aa distance was relatively small (0.88 ± 0.25 cm), indicating a milder degree of prolapse. The Ba measurement (0.60 ± 0.40 cm) was also significantly smaller than that of the other groups (1.63 ± 0.33 cm), confirming that prolapse was milder in this group. Significant intergroup differences were also observed according to other POP Q variables (C, D, Ap). Therefore, pre operative POP Q values varied depending on the mesh shape.

The proportion of patients with stress urinary incontinence before surgery ranged from 16.3 % to 27.3 % across groups, and these differences were not statistically significant (p > 0.05).

The proportion of patients with latent urinary incontinence before surgery varied widely—between 2.3 ± 2.3 % and 11.9 ± 4.2 %—but this variation was not statistically significant (p > 0.05). A similar absence of significance was found for the frequency of patients with detrusor overactivity (3.0 ± 2.9 % – 6.8 ± 3.3 %, p > 0.05).

After surgery, anatomical improvement across all groups was almost identical and did not show marked changes within 12 months (Table 3). Differences in POP Q parameters at 12 months were not significant (p > 0.05), but some variations were observed in the dynamics of functional disorders.

The proportion of patients showing detrusor hyperactivity remained unchanged in one group and increased in the other two groups, but the difference was not statistically significant (p > 0.05). A comparable pattern was observed for the frequency of recurrences (p >0.05).

Thus, the anatomical and functional outcomes of laparoscopic sacropexy with mesh did not differ significantly depending on mesh shape. However, the frequencies of recurrence showed statistically significant differences.

The overall incidence of both cystocele and apical prolapse recurrences differed significantly depending on mesh configuration:

- for a flat mesh placed only on the posterior vaginal wall: 18.2 ± 5.4 %,

- for a flat mesh placed on anterior + posterior walls: 23.2 ± 6.4 %,

- for Y shaped mesh: 6.8 ± 3.3 %.

Based on these findings, the Y-shaped mesh proved to be the most effective configuration.

Table 1: Clinical and anatomical characteristics of patients in groups with different mesh shapes used for laparoscopic sacropexy

Table 2: Main intra operative characteristics of laparoscopic sacropexy (% , M ± m, p < 0.05)

Table 3: Outcomes of laparoscopic sacropexy according to mesh shape (pre  and 12 months post operation; p < 0.05)

There is no published evidence directly assessing changes in the outcomes of laparoscopic sacropexy in relation to the shape of the mesh used. However, in general, the results of this procedure have been widely discussed in the literature.

A study conducted in Berlin reported that during follow up of up to eight months after laparoscopic sacropexy, the recurrence rate was 10.4 %. [18]

In our observations, recurrence rates over 12 months depended on mesh shape:

– for Y shaped mesh – 6.8 ± 3.3 %;

– for flat mesh applied only to the posterior vaginal wall – 18.2 ± 5.9 %;

– for flat mesh applied to both anterior and posterior vaginal walls – 23.2 ± 6.4 %.

Although the overall comparison showed no statistically significant differences (p > 0.05), attention should be drawn to the lower recurrence rate achieved with operations employing the Y shaped mesh.

According to published data, within 24 months after laparoscopic sacropexy, the frequency of repeat operations reaches 12.8 % [2]. In our study, this indicator was 12 %, while the requirement for repeated intervention was much lower:

– 0 % in the group with posterior flat mesh;

– 4.6 ± 3.2 % for the anterior + posterior flat mesh;

– 1.69 ± 1.69 % for the Y shaped mesh.

Thus, the conducted observations demonstrate that laparoscopic sacropexy using meshes of different configurations generally yields successful outcomes.

Laparoscopic sacropexy with the use of a flat mesh on the posterior vaginal wall, a flat mesh on both anterior and posterior walls, and a Y shaped mesh provided comparable anatomical and functional outcomes.

However, recurrence frequencies differed among groups – 18.2 ± 5.9 %, 23.2 ± 6.4 %, and 6.8 ± 3.3 %, respectively.

The Y-shaped mesh demonstrated a lower rate of recurrence, making it the most effective option among the tested configurations for laparoscopic sacropexy in the treatment of genital prolapse.